OMB No. 0730-0012
OMB approval expires
Mar 31, 2010
The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0730-0012). Respondents should be aware that notwithstanding any other provision of law, no
person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED REPORT TO:
Defense Finance and Accounting Service
Continuing Government Activity (CGA)
P.O. Box 998021, Room 2323
Cleveland, OH 44199-8021
PRIVACY ACT STATEMENT
AUTHORITY: 37 USC Chapter 11; EO 9397.
PRINCIPAL PURPOSE: To report on the administration of the funds received on behalf of a mentally incompetent member of the uniformed services.
ROUTINE USE(S): Information may be released to the Internal Revenue Service for tax administration; General Accounting Office for auditing;
Department of Veterans Affairs for pay entitlements; Social Security Administration for pay entitlements; American Red Cross for locator service;
military aid societies for family assistance; and Office of Personnel Management for pay entitlements.
DISCLOSURE: Voluntary; however, if the information is not provided, an appointment of a trustee cannot be made.
INSTRUCTIONS FOR COMPLETING THIS FORM
As a Trustee, you are required to deposit all DoD funds received in a separate bank account, set up under your name as Trustee for the service
member. A report of the administration of the funds received is required by this office. These reports must show dates (month and year), total
amounts, and reasons for payments made. The back of this form may be used for reporting this information. Bank statements must be furnished to
support payments made. Failure to return this form with the required documents, failure to keep proper records of the money spent, or the improper
use of military pay may result in the withholding of future funds and termination of your Trusteeship. Obtain permission from this office for purchases
of$500 or more, other than normal living expenses. Return completed form to the above address.
SECTION I - INFORMATION ABOUT THE SERVICE MEMBER
1. NAME (Last, First, Middle Initial)
3. SOCIAL SECURITY NUMBER
4. STATUS OF MEMBER (X one)
(If member is not at home, give name and address of facility)
SECTION II - SUMMARY OF PAY RECEIVED AND EXPENDED
6. PERIOD COVERED
5. AS OF (YYYYMMDD)
b. TO (YYYYMMDD)
a. FROM (YYYYMMDD)
7. CHECKING ACCOUNT NUMBER(S)
8. SAVINGS ACCOUNT NUMBER(S)
9. NAME AND ADDRESS OF BANK
10. NAME AND ADDRESS OF SAVINGS INSTITUTION
11. BEGINNING BALANCE (Line 16 from previous report)
12. TOTAL MILITARY PAY RECEIVED THIS ACCOUNTING PERIOD
13. TOTAL AMOUNT AVAILABLE THIS ACCOUNTING PERIOD (Add Lines 11 and 12)
14. AMOUNT OF SAVINGS
15. TOTAL AMOUNT PAID DURING THIS ACCOUNTING PERIOD (Totals from Page 2)
16. TOTAL EARNINGS REMAINING AT END OF ACCOUNTING PERIOD (Subtract Line 15 from Line 13):
a. SAVINGS ACCOUNT
+ b. CHECKING ACCOUNT
+ c. OTHER INVESTMENTS (Specify in Remarks on back)
SECTION III - AFFIDAVIT
The balance as shown above is deposited in bank or trust company as verified by bank account statements attached. The accounting herein
represents an accurate accounting of all monies received and expended for the benefit of member named for the period shown.
17. TRUSTEE'S NAME (Last, First, Middle Initial)
18. RELATIONSHIP TO
DD FORM 2826, MAR 2007
PREVIOUS EDITION IS OBSOLETE.
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